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Excerpt
I read with interest the article on acute noncontact compartment syndrome by Drs. Mallik and Diduch (J Orthop Trauma 2000;14:509–10).
Drs. Mallik and Diduch (10) claim that “prolonged positioning of an extremity has not been previously described as a cause of compartment syndrome” and present their case as the first ever of positional noncontact compartment syndrome. However, a Medline search (University of New South Wales, Biomedical Library, Ovid Medline) reveals quite a few articles reporting just this type of injury (1,4,7). Most of these relate to compartment syndrome developing secondary to a lithotomy position (4) or traction for fracture fixation (1,7). The mechanism of injury seems to be similar to the one described by Mallik and Diduch (10); prolonged dependency and/or acute limb flexion causing venous stasis.
Compartment syndrome is common in comatose patients (5,9,12) and in drug addicts (14). Most of these cases, however, are caused by prolonged recumbency in one position with a subacute crush injury to a part of the body (2,3,8,14).
A similar type of noncontact compartment syndrome is also seen in some drug addicts. I have had the opportunity to work in two hospitals that are situated in areas with a substantial concentration of people who abuse drugs, both casual users and hardened drug addicts. A popular practice was for the users to lock themselves in public toilets and inject themselves. Those who passed out did so in a sitting position in the crammed confines of the toilet. Most of these people were discovered by the authorities only after many hours of sitting in one position.
A total of 14 cases of this type were treated over a two-year period. On arrival at the emergency room, many of these patients had clinical signs of an acute compartment syndrome. The tibial compartments were most commonly involved. The anterior-lateral and medial femoral compartments were occasionally involved. The femoral compartments were involved in all five patients that were found in a squatting position. The squatting or the crouched position (10) causes increased pressure in the groin crease leading to venous outflow obstruction. If the user had slumped forward with upper limbs in a dependent position, but not necessarily under direct pressure of another body part, the upper limbs were also affected. This was seen in four cases.
The gluteal and posterior femoral compartments, which suffered a direct crush injury from the prolonged sitting posture, presented as compartment syndromes only after initial resuscitation. This presentation could be delayed by up to seventy-two hours from the initial event. This was seen in eight cases.
The patients were always resuscitated and intubated in the emergency room, requiring varying levels of ventilatory assistance. All patients required reversal of narcosis. Most patients were oliguric on arrival. All patients were considered at a risk of rhabdomyolysis (11,13,14) and related renal impairment. All patients were therefore given sodium bicarbonate infusions and forced alkaline diuresis (11). All patients had myoglobinuria for an average of three days, but none required dialysis (8). Four triggers for a surge in serum myoglobin levels were noted:
The signs of increased compartment pressure were not always evident and one needs a high index of suspicion, especially in a noncooperative or comatose patients. The Stryker pressure-monitoring device is very useful in such situations (6,10).
These patients must be treated as trauma patients and have a complete Emergency Management of Severe Trauma (EMST) (Royal Australian College of Surgeons, Road Trauma Committee, Melbourne, Australia)/Advanced Trauma Life Support (11) management, including primary and secondary clinical survey for head and spinal trauma, thoracoabdominal trauma, and limb trauma.
